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First pass effect in patients with large vessel occlusion strokes undergoing neurothrombectomy: insights from the Trevo Retriever Registry
  1. Ashutosh P Jadhav1,2,
  2. Shashvat M Desai3,4,
  3. Ronald F Budzik5,
  4. Rishi Gupta6,
  5. Blaise Baxter7,
  6. Joey D English8,
  7. Bruno Mario Bartolini9,
  8. Antonin Krajina10,
  9. Diogo C Haussen11,
  10. Raul G Nogueira12,
  11. David Liebeskind13,
  12. Erol Veznedaroglu14
  1. 1Department of Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
  2. 2Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
  3. 3Department of Neurology and Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
  4. 4Department of Neurology, Barrow Neurological Institute, Phoenix, Arizona, USA
  5. 5Riverside Methodist Hospital, Columbus, Ohio, USA
  6. 6Department of Neurology, WellStar Health System, Marietta, Georgia, USA
  7. 7Department of Radiology, Erlanger Medical Center, Chattanooga, Tennessee, USA
  8. 8California Pacific Medical Center, San Francisco, California, USA
  9. 9Department of Neuroradiology, CHUV, Lausanne, VD, Switzerland
  10. 10Department of Radiology, Hradec Kralove, Czech Republic
  11. 11Department of Neurology, Neurosurgery, and Radiology, Emory University School of Medicine/Marcus Stroke & Neuroscience Center - Grady Memorial Hospital, Atlanta, Florida, USA
  12. 12Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
  13. 13Department of Neurology, UCLA, Los Angeles, California, USA
  14. 14Department of Neuroscience, Drexel University, Philadelphia, Pennsylvania, USA
  1. Correspondence to Dr Ashutosh P Jadhav, Department of Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; jadhav.library{at}


Background First pass effect (FPE), defined as near-total/total reperfusion of the territory (modified Thrombolysis in Cerebral Infarction (mTICI) 2c/3) of the occluded artery after a single thrombectomy attempt (single pass), has been associated with superior safety and efficacy outcomes than in patients not experiencing FPE.

Objective To characterize the clinical features, incidence, and predictors of FPE in the anterior and posterior circulation among patients enrolled in the Trevo Registry.

Methods Data were analyzed from the Trevo Retriever Registry. Univariate and multivariable analyses were used to assess the relationship of patient (demographics, clinical, occlusion location, collateral grade, Alberta Stroke Program Early CT Score (ASPECTS)) and device/technique characteristics with FPE (mTICI 2c/3 after single pass).

Results FPE was achieved in 27.8% (378/1358) of patients undergoing anterior large vessel occlusion (LVO) thrombectomy. Multivariable regression analysis identified American Society of Interventional and Therapeutic Neuroradiology (ASITN) levels 2–4, higher ASPECTS, and presence of atrial fibrillation as independent predictors of FPE in anterior LVO thrombectomy. Rates of modified Rankin Scale (mRS) score 0–2 at 90 days were higher (63.9% vs 53.5%, p<0.0006), and 90-day mortality (11.4% vs 12.8%, p=0.49) was comparable in the FPE group and non-FPE group. Rate of FPE was 23.8% (19/80) among basilar artery occlusion strokes, and outcomes were similar between FPE and non-FPE groups (mRS score 0–2, 47.4% vs 52.5%, p=0.70; mortality 26.3% vs 18.0%, p=0.43). Notably, there were no difference in outcomes in FPE versus non-FPE mTICI 2c/3 patients.

Conclusion Twenty-eight percent of patients undergoing anterior LVO thrombectomy and 24% of patients undergoing basilar artery occlusion thrombectomy experience FPE. Independent predictors of FPE in anterior circulation LVO thrombectomy include higher ASITN levels, higher ASPECTS, and the presence of atrial fibrillation.

  • thrombectomy

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  • Correction notice This article has been corrected since it first published. The provenance and peer review statement has been included.

  • Contributors Conception and design: all authors. Acquisition of data: all authors. Analysis and interpretation of data: all authors. Drafting the article: APJ. Critically revising the article: all authors. Administrative/technical/material support: all authors. Study supervision: APJ.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests RG: principal Investigator: ASSIST Registry, Stryker Neurovascular; modest compensation; principal Investigator: Tiger Retriever Study, Rapid Medical; modest compensation, principal Investigator: Recclaim trial, Zoll Medical; consultant Cerenovus, modest Compensation. BB receiving consulting fees and fees for serving on a speakers’ bureau from Penumbra and consulting fees from Medtronic, Route 92 Medical,, 880 Medical, Marblehead Medical, Rapid Medical, Metactive, and holding U.S. patent 9 526 863 on devices and methods for perfusion therapy, licensed to Neuronal Protection System;.DCH is a consultant for Vesalio;.stock options from RGN reports potential conflicts with Stryker Neurovascular (DAWN Trial principal investigator–no compensation, TREVO Registry Steering Committee–no compensation, Trevo-2 Trial principal investigator– modest; consultant–modest), Medtronic (SWIFT Trial Steering Committee–modest; SWIFT-Prime Trial Steering Committee–no compensation; STAR Trial Angiographic Core Laboratory–significant), Penumbra (3D Separator Trial Executive Committee–no compensation), Cerenovus/ Neuravi (ENDOLOW Trial principal investigator, EXCELLENT Registry principal investigator, ARISE-2 trial Steering Committee–no compensation, Physician Advisory Board, modest), Phenox (Physician Advisory Board, modest), Anaconda (Physician Advisory Board, modest), Genentech (Physician Advisory Board–modest), Biogen (Physician Advisory Board–modest), Prolong Pharmaceuticals (Physician Advisory Board–modest), Allm Inc. (Physician Advisory Board–no compensation), IschemaView (speaker, modest), Brainomix (Research Software Use–no compensation), Sensome (Research Device Use–no compensation), Viz-AI (Physician Advisory Board, stock options), Philips (Research Software Use–no compensation, Speaker–modest), and Corindus Vascular Robotics (Physician Advisory Board, stock options). DL: consultant at imaging core laboratory for Cerenovus, Genentech, Medtronic, Rapid Medical, Stryker, Vesalio.

  • Provenance and peer review Not commissioned; externally peer reviewed.